The UN multi-stakeholder meeting on pandemic prevention, preparedness and response.

The global response to COVID-19 failed people in developing countries, women and health workers and must never be repeated, non-state actors told a meeting hosted by the United Nations (UN) in New York on Tuesday.

The UN convened the four-hour multi-stakeholder meeting on pandemic prevention, preparedness and response (PPPR) in preparation for a High-Level Meeting (HLM) on the issue in September, which will adopt a political declaration.

Dr Joanne Liu, representing the Independent Panel for PPR, told the meeting that Ebola would not have been defeated without high-level political leadership, and the same was necessary to address future pandemics.

“We need the highest level of political attention on pandemic threats because they are overwhelming, complex and have a multi-sectoral impact,” said Liu. “A leader-led Global Health Threat Council is essential to sustain global pandemic readiness.”

Lui added that “it is certain that new pandemic threats will emerge, but full-blown pandemics are a political choice.

“This September, the UN General Assembly has the historical opportunity to choose to make COVID-19 the last pandemic of such devastation.”

Health threats council?

In a recorded message, World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus supported “the proposal for a health threats council as a forum for high-level political leadership”. 

However, he warned that such a council had to be “grounded in WHO constitutional mandate and complement and strengthen existing governance structures, including the World Health Assembly and the Standing Committee on Health Emergency Prevention, Preparedness and Response, which the WHO’s executive board established last year”. 

Otherwise “we face the risk of establishing multiple disconnected initiatives that drive further fragmentation”, he added.

But Nina Schwalbe, representing the UN University’s International Institute of Global Health, advocated for a high-level council to hold member states accountable for their commitments to PPR that was independent of the WHO.

“As has been evidenced by other sectors, including human rights, chemical weapons, climate and atomic energy, signing a treaty is not enough,” she noted. 

“Compliance requires independent monitoring. Reporting to the highest level of government, a high-level political council made up of heads of state and their representatives can drive cross-national, multisectoral accountability and monitor member states compliance with the pandemic accord,” she added.

Meanwhile, the Pandemic Action Network called for “a robust set of monitoring and accountability mechanisms in the high-level declaration, starting with a progress review within 12 months of the summit”. 

Nurses from the primary care team at the Gonçal Calvo Health Centre in Spain test for COVID-19.

Addressing inequity

“The primary manifestation of inequality was the inequitable distribution of vaccines,” said Dr Carlos Correa of the South Centre. “The COVAX mechanism failed to achieve equitable distribution of vaccines not only due to financial reasons but because the governance of the system was not multilateral in nature.”

Amnesty International noted that 28% of COVID-19 deaths were in Latin America and the Caribbean, yet it is home to only 8.4% of the world’s population.

“Our societies suffer a rampant inequality that excludes entire populations from health systems, especially women and indigenous peoples,” it noted.

The Medicines Patent Pool (MPP) said it was possible to include equitable access conditions in funding agreements to help “address questions of affordable access long before the product comes to market”. 

“This is especially important in the context of PPPR. Public, multilateral and charitable financing of r&d can be conditioned on funded entities taking sufficient measures by voluntary licencing or otherwise, to ensure that every medical technology is available and affordable to all,” said the MPP.

Meanwhile, the People’s Vaccine Alliance wants any political declaration to “enable local production to ensure a sustained supply of countermeasures”. 

“That means a commitment to sharing technology, removing intellectual property barriers, investing in r&d in the south, and investing in actual manufacturing,” said the alliance’s Mohga Kamal-Yanni.

Protecting healthworkers 

“The pandemic exacted a huge toll on the physical and mental health of health workers around the world, infecting millions and causing the deaths of more than 180,000,” said Pamela Cyriano from the International Council of Nurses.

“Excessive” burnout and the ageing of the workforce are exacerbating the already existing shortage of six million nurses, half of which are in our African nations. 

“Healthcare workers stepped up for COVID and put their lives on the line. But we have to ask, will they be there the next time,” she said, calling for the investment in fair and decent pay and in the training new nurses,” sakis Cyriano.

David Bryden, director of the Frontline Healthworkers Coalition, also pointed out that “migration of health workers, in particular nurses, from low and middle-income countries to high-income countries has increased dramatically in recent years, putting pandemic response capacity at risk in their countries of origin”.

More parliamentary involvement

Ricardo Baptista Leite, president of UNITE Parliamentarians’ Network for Global Health

Ricardo Baptista Leite, president of UNITE Parliamentarians’ Network for Global Health, urged more involvement of Members of Parliament in negotiations on a pandemic accord, currently coordinated by the WHO.

“I was in a meeting of 300 MPs recently and asked who had heard of the pandemic accord and no one put up their hand,” said Leite, pointing out that MPs pass the budgets of countries and are thus essential in securing finances for pandemic preparedness.

Leite also urged more action against the deluge of misinformation that is undermining public trust in medicines and vaccines.

Angela Kane, Senior Advisor to the Nuclear Threat Initiative.

Angela Kane, former UN Undersecretary General and Senior Advisor to the Nuclear Threat Initiative, said that there were “significant gaps” in international mechanisms to help figure out the source of biological events.

The WHO “is well positioned to assess outbreaks of natural origin, so-called spillover from animals to humans”, said Kane, adding that it is “still deciding how far it will go to assess an outbreak origin once signs begin to emerge that it may have resulted from a lab accident or deliberate bioweapons attack”. 

“This is an important decision because WHO needs to maintain the trust and openness of its member states to carry out its public health mission and engaging in security-related issues could make that difficult,” said Kane.

On the other end of the spectrum the UN Secretary-General has the authority to investigate allegations of deliberate bioweapons use –  but only when there were brought to it by member states and this had never happened.

“There is no mechanism in the UN system to assess events of unknown origin that fall between the scope of these two mandates,” said Kane. “Are we doing enough to rapidly identify cases where there’s ambiguity about a source of an outbreak?

“The challenges of discerning COVID-19 origins have highlighted the need to fill this gap for determining the origins of a disease outbreak in a form that is scientifically based.”

The multi-stakeholder meeting was one of a trio – the others dealing with tuberculosis and universal health coverage – held this week in preparation for the UN HLMs on these three issues over three consecutive days from 20-22 September.

Image Credits: Consorcio Sanitario del Maresme, Spain.

Registered nurses Fatmata Bamorie Turay (left) and Elizabeth Tumoe, look after newborns at the Princess Christian Maternity Hospital, in Freetown, Sierra Leone.

As the United Nations multi-stakeholder meeting on universal health coverage (UHC) convenes on Tuesday afternoon in New York,  we urge that women health workers are properly recognized and rewarded

The global health workforce crisis is no longer a looming possibility. It is a reality. Pre-pandemic the World Health Organization (WHO) projected a global shortage of 10 million health workers by 2030 and since then the situation has significantly deteriorated. Staff shortages are reported ever more frequently, health workers strike more often and high-income countries increase their incentives for nurses to move from low-income countries.

So why is it that recent international documents on global health, including the G7 foreign ministers’ communique on 18 April, fail to acknowledge the crucial role of health workers in the achievement of universal health coverage (UHC)? Why don’t health ministers and heads of state address the real reasons for the emptying rosters, the rock-bottom morale and the sky-high burnout?

Women make up a significant majority of the health workforce, comprising 70% of overall health and care workers and 90% of frontline staff. They lead the delivery of health to five  billion people and contribute an estimated $3 trillion annually to global health, half in the form of unpaid work. They are the backbone of our health systems.

Underpaid, excluded from leadership

But this is how we reward them. They are paid 24% less on average than their male counterparts – if they are paid at all. There are plenty, in fact six million of them estimated to be grossly underpaid or unpaid. As Samantha Power, Administrator of USAID, rightly acknowledged recently, there should be no such thing as working for free when you are providing lifesaving care.

Three-quarters of all leadership roles in health go to men who benefit from a male bonus syndrome of more opportunities for promotion, higher salaries and lower expectations at home for family care.  

Workplaces are increasingly unsafe, with reports of increased gender-based violence in health rising. There are issues with sexual abuse, exploitation and harassment.  

During the pandemic, women have suffered from a lack of infection control equipment or if it was available, trying to adjust personal protective equipment purchased in men’s sizes, increasing the risk they faced. They were the ones on the front lines, trying to explain why services like sexual and reproductive health care had been deprioritised and there was no support available. 

Women HCWs experience sexual harassment at workplace.
Two women healthcare workers caring for an infant.

Opportunity for a reset

This year is an opportunity for a reset. Heads of state will travel to the UN on 21 September and release a new global commitment to Universal Health Coverage.  

In advance of this, on 8-9 May, they have invited civil society to give suggestions for what to include in their negotiations.

While diplomats might be overwhelmed with a long list of asks, we want to remind them that health does not deliver itself.  Vaccines, drugs and technology are no good sitting in storage.  Hospitals and health centers are just buildings and beds without nurses or doctors. There is no early warning system for disease, no maternal care and no programs for primary health care unless staff are trained, retained and on shift.

So, for the governments who are preparing the negotiations, here is our prescription for prevention:

  • Fully deliver on all commitments to gender equality and the rights of women and girls in UHC, made at HLM 2019
  • Guarantee gender equality in health systems leadership and  decision-making at all levels, including use of quotas and targets for women in leadership and all-women shortlists for selection until gender parity is achieved. Give particular attention to geographical diversity
  • Close the gender pay  gap, and value and appropriately remunerate unpaid and underpaid health and care workers, including community health workers
  • Design, properly resource and deliver health systems based on gender-responsive policies and health services and the elimination of gender inequality and discrimination
  • Resource and deliver universal access to sexual and reproductive health services as essential services, and mainstream them in national health policy frameworks
  • Monitor and evaluate progress towards universal health coverage in data and analyses disaggregated by sex, gender identity and other relevant stratifiers

 Women health and care workers have faced systemic bias and traumatizing work conditions. If the world wants operating health systems, governments have an opportunity to check the lists and triage women health workers to the top.

Dr Roopa Dhatt is Co-Founder and Executive Director, of Women in Global Health.

Sharan Burrow is the former General Secretary of the International Trade Union Confederation

Image Credits: World Bank/Flickr, Photo by Mufid Majnun on Unsplash.

TB activists attend a community assembly in New York’s Battery Park to call for more investment in TB vaccines and treatments.

The United Nations (UN) is hosting three multi-stakeholder meetings in New York on Monday and Tuesday on tuberculosis, pandemic prevention, preparedness and response (PPPR) and universal health coverage (UHC).

They are aimed at getting the views of non-state actors in preparation for UN High-Level meetings in September, starting with pandemic preparedness on 20 September, followed by UHC, then TB on consecutive days.

On Sunday, a community assembly was held in New York’s Battery Park to call for more investment in TB, the second-biggest infectious disease killer after COVID-19. It included the public reading of the TB vaccine R&D investment open letter signed by almost 1200 individuals and organisations around the world.

“We have seen before that investing in averting TB deaths can bring significant economic benefits! Every dollar invested in this effort returns an average of $43 dollars, making it a smart and impactful investment for communities and economies alike,” said Kate O’Brien from We are TB USA.

“We need new TB vaccines to end TB, mitigate the impact of COVID-19 on the global TB response, and control the spread of drug-resistant TB, a key driver of antimicrobial resistance. Yet, the only available TB vaccine is the century-old Bacillus Calmette-Guérin (BCG) which is largely ineffective in adolescents and adults,” said Keyuri Bhanushali, a TB survivor and activist from Mumbai, India.

“Let’s invest in TB vaccine R&D to finally put an end to this devastating pandemic.”

Lack of consultation over pandemic and UHC meetings

However, some civil society participants told Health Policy Watch that there had been little consultation about participation, particularly in relation to the pandemic and UHC meetings, including over speakers on the panels and the procedures to be followed.

Many organisations had invested in bringing affected people from other parts of the world to the UN meetings yet they were unsure of whether they would be able to speak from the floor. In addition, they questioned why organisations’ statements would be loaded onto the website of the World Health Organization (WHO), not that of the UN.

In response, Paulina Kubiak, spokesperson for the President of the General Assembly (PGA), told Health Policy Watch that there had been “an open registration process on the UN Indico website for stakeholders to participate in the multi-stakeholder hearings”, with registration open from 2 March to 7 April. 

“The panellists were selected in accordance with the relevant resolutions of the General Assembly which require the PGA to organize the multi-stakeholder hearings with the support of the WHO and other relevant partners (Stop TB Partnership in the case of TB and UHC2030 in case of UHC),” said Kubiak.

“Written statements can be submitted by participants until May 15 and will be available on the WHO website in due course (pending the volume of submissions).”

The meetings are being broadcast live on the UN webTV:

Image Credits: UN Photo/Manuel Elias.

TibuHealth allows Kenyans to book medical appointments and tests online

Barriers to inclusive health are spurring African innovators into action. But to build an inclusive health system the continent needs to address structural inequalities – political, social and economic – and this will require that private and public partners alike embrace radical collaboration to support inclusive innovation.

When public health graduate student, Jason Carmichael, arrived in Kenya in 2013, he noticed numerous gaps in the healthcare system that troubled him. There were not enough hospitals. Doctors were not always working full-time or at full capacity, and patients were not getting the care they needed. Then he met Kenyan tech whizzkid, Peter Gicharu. They pooled their expertise and started testing models aimed at connecting the dots between healthcare providers and patients.

Fast forward to 2018, and the launch of TibuHealth, a social enterprise that delivers health services directly to those who need them. Born of the curiosity of two people about how to do things better, the system allows patients to request medical consultations, sample collections and vaccinations in their home or other chosen location using an app, website, customer support line or email.

This kind of scheduling capacity means that there is burden-shifting from the public sector to the private sector, lightening the load felt by public sector institutions. Tibu’s services cost Ksh 1,850 (US$15.80) while a typical GP charges Ksh 1,800 – 3,000. 

TibuHealth is one of the hundreds of social enterprises in sub-Saharan Africa doing extraordinary work solving healthcare challenges in innovative and often very practical ways. 

Innovating to overcome barriers 

Social enterprises are emerging as critical actors in African healthcare systems, rising to prominence during the COVID-19 pandemic where they played a key role in bolstering government responses across the region.

Where others see challenges, social innovators like Gicharu and Carmichael see opportunities. Typically, these innovative actors harness community-centred approaches and inclusive solutions to close the gaps in healthcare delivery. By their nature, they are willing to take risks to create change. They also have the local insight and business sense to turn their ideas into reality.

 According to a new White Paper published by the World Economic Forum on Innovation towards health equity in Africa, there are 10 common barriers to inclusive healthcare that social innovators across the continent are working to dismantle. The analysis included an AI scan of 450,000 pieces of content across 48 African countries and eight languages, in addition to 35 interviews and three verification workshops in 2022. 

It found that the majority of healthcare innovations (about 65%) were seeking to address issues such as weak healthcare capacity and infrastructure, the lack of access and affordability of quality healthcare and medicine, the economic impact of COVID-19, and inequality related to COVID-19 – particularly the low COVID-19 vaccination rate, due, partly to vaccine hoarding by wealthier countries. 

Other major themes included stigmatization, health literacy, digitalization and the inaccessibility of data, gender inequality, malnutrition and food insecurity, access to basic needs, and supply chain disruptions and logistic challenges.

Fundamental shift needed

But while the solutions these innovators are coming up with are ingenious and many of them are making a huge impact, on their own they won’t be enough to build a more equitable health system in Africa. As health inequality is a systems problem, it will require a systemic response.

The WEF White Paper makes the point that, to fully realise the potential of social health entrepreneurs, a fundamental shift needs to take place towards a broader health equity agenda. There needs to be a recognition that social, political and economic factors are all integral to developing fairer health systems and this will require an all-out collaboration across all sectors to create an environment that enables innovation for equity.

To build such an enabling ecosystem, attention would need to be paid to formal elements, such as public policies, governance structures, regulatory frameworks and investment programmes, and informal elements such as cultural, social and economic norms and practices.

Key principles to build equity

We believe that four key principles are necessary to underpin this work.

First, social innovators and their corporate and government partners need to build for the long haul. This means that, rather than rushing to develop a competitive solution, they need to take the time to develop their business model and authentically engage with their customers and partners to create an interconnecting web of reciprocal relationships which will help to lay solid foundations for the enterprise.

Second, they would need to be prepared for the reality that in complex systems progress is not linear. As Margaret Wheatley, the systems theorist, wrote: “We live in a world of complex systems whose very existence means they are inherently uncontrollable”. To put this another way, we need to make friends with the reality that setbacks in this line of work are common.

Building for the long haul and being clear-eyed about the nature of progress and success are key traits that encourage entrepreneurial resilience, the third key principle of an inclusive health system. If the COVID-19 pandemic showed us one thing it was that resilience – the ability to withstand and overcome adversity – is not necessarily an inherent trait but a muscle that must be exercised as individuals, teams, and organisations. 

Healthcare innovators and their partners then must take care to put in place practices to build their resilience muscle. This could include developing robust feedback loops that allow for open communication, real-time change and strong bonds between stakeholders. The ability to learn and adapt is a key factor in resilience.

Lastly, to build inclusive healthcare systems it will be necessary to embrace radical partnerships and opportunities for collaboration between different disciplines, institutions, businesses, multilaterals and government departments. 

Health equity is everyone’s business. Every actor in the ecosystem needs to do what they can to support the innovation and resilience of social entrepreneurs and innovators at ground level and they need to work together to go further.

Unlocking such partnerships will require greater levels of trust and mutual understanding between government business and societal actors, and this will take hard work to build. But build it we must because, without it, it is unlikely that we will get close to achieving true health equity in Africa. And sick and vulnerable people across the continent will continue to be excluded from life-saving care.

 

Katusha de Villiers is Health Systems Innovation Lead for the Bertha Centre for Social Innovation and Entrepreneurship at the University of Cape Town.

Gillian Moodley is a Project Manager at the Bertha Centre for Social Innovation and Entrepreneurship at the University of Cape Town. 

Both contributed to the new white paper on Innovation towards health equity in Africa, published by the World Economic Forum.

 

WHO Director General Dr Tedros Adhanom Ghebreyesus declares an end to the COVID-19 global public health emergency – but warns disease remains a threat.

The COVID global health emergency is over, said WHO Director General Dr Tedros Adhanom Ghebreyessus at a press conference on Friday.  His declaration came more than 39 months after WHO first declared a public health emergency of international concern (PHEIC) on 30 January 2020 over a mysterious respiratory virus that emerged in Wuhan, China but quickly overcame countries around the world.

Speaking at a media briefing, the WHO DG warned that the disease remains a threat along with multiple other stressors threatening global health and security – from climate change to weak health systems. Taken together, these could soon lead to yet another pandemic if not forcefully addressed.

He called upon political leaders to move quickly to finalise the terms of a new Pandemic Accord being negotiated by WHO member states, as well as agreeing to revisions in WHO’s existing International Health Regulations so as to “transform that suffering” of COVID 19 into “meaningful and lasting change” with a “commitment to future generations that we will not go back to the old cycle of panic and neglect that left our world vulnerable.”

He noted that “COVID-19 turned our world upside down” with a reported death toll of seven million deaths but a likely actual death toll of close to 20 million.

And “the virus is here to stay” he stressed, warning countries not to let down their guard.

Litany of damage

Coronavirus lockdown in a Roma community in Romania in May 2021. Poverty made social distancing and basic hygiene rules difficult, if not impossible, for billions.

In the warm-up to his announcement, the WHO DG reviewed the litter of global damage wrought by the virus that ripped like a hurricane through societies worldwide in early 2020:

“COVID has been so much more than a health crisis,” Tedros observed.  “it has caused severe economic upheaval, shaving trillions from GDP, disrupting travel and trade, shattering businesses and throwing millions into poverty.

“It caused severe social upheaval, with borders closed, movements restricted and schools shut, and millions of people experiencing loneliness, isolation, anxiety, and depression.

“COVID-19 has exposed and exacerbated political lines within and between nations.|

“It has eroded trust between people, governments and institutions, fueled by a torrent of myths and misinformation. And it has laid bare the searing inequalities of our world – with the poorest and most vulnerable communities the hardest [hit] and the last to receive vaccines and other tools.”

But in light of the steady downward trend in COVID-related mortality, brought about by a weakening virus, growing population immunity and increased vaccination rates, WHO’s COVID-19 Emergency Committee “recommended to me that I declare an end to the Public Health Emergency of International Concern (PHEIC), ” he said.  He was referring to the emergency provisions of WHO’s International Health Regulations (IHR) that legally obligate WHO members states to act on public health threats.

The Emergency Committee made its recommendation following a meeting Thursday in Geneva – the 15th such gathering since the SARS-CoV2 virus was first reported in Wuhan in early January 2020.

COVID is over as a global health emergency – but not as a global health threat

An Italian border guard checks the temperature of an arriving airline passenger in April 2020, as the first wave of the COVID pandemic crested.

“It’s therefore with great hope that I declare COVID-19 over as a global health emergency. However, that does not mean COVID-19 is over as a global health threat,” Tedros cautioned.

“Last week COVID-19 claimed one life every three minutes – and that’s just those that we know.  As we speak thousands of people around the world are fighting for their lives in intensive care units. And millions more continue to live with the debilitating effects of post COVID-19 conditions.

“This virus is here to stay. It’s still killing. And it’s still changing; the risk remains of new variants emerging that cause new surges in cases. So the worst thing any country could do now is to use this news as a reason to dismantle the systems it has built or to send the message to its people that COVID-19 is nothing to worry about.”

“This is not a signal for us to lower our guard”: Didier Houssin, head of the WHO COVID Emergency Committee

“This is not a signal for us to lower our guard,” added Didier Houssin, head of the WHO COVID Emergency Committee that had met Thursday and issued its recommendation to WHO for the COVID state of emergency to finally be lifted.

What the announcement does reflect, however, is that “it’s time for countries to transition from emergency mode to managing COVID-19 alongside other infectious diseases,” Tedros said.

With that in mind, he said that he would deploy a “never used” provision in the WHO International Health Regulations, to establish a standing COVID Review committee to make and update recommendations to countries about management of the virus on an on-going basis.

Declaration was not unexpected

A WHO declaration on the end of the global health emergency had been anticipated for sometime, Tedros and other WHO officials speaking at the Friday briefing admitted.

“I emphasize that this is not a snap decision,” Tedros said. “It’s a decision that has been considered carefully for some time, planned for, and made on the basis of careful analysis of the data.”

WHO’s release Wednesday of an updated COVID-19 Global Strategic Preparedness, Readiness and Response Plan (SPRP) 2023-2025” had fueled speculation among seasoned WHO-watchers that an announcement was imminent.

Is the COVID Pandemic Over?

The document was billed as a guide for managing COVID “in the transition from an emergency phase to a longer-term, sustained response”.

Alongside reducing circulation of the SARS-CoV-2 virus and diagnosing and treating COVID-19, a third objective of the plan is to “to support countries as they transition from an emergency response to longer-term sustained COVID-19 disease prevention, control and management”, the WHO DG stated in a foreword.

Worldwide, countries have also gone back to near normal – with lockdowns and social distancing giving way to packed cafes and theatres.  Masking remains visible in some venues like airports and subways – but at a voluntary bare minimum.  And government travel and emergency decrees have now been lifted in even the most COVID-wary nations, like Japan and China – the latter of which saw a big wave of cases in late 2022 after intense public protests led to the removal of most domestic restrictions.

Coincidentally or not, the United States is also set to announce an end to its national COVID emergency next week, on 11 May.  That will see the lifting of most federal COVID vaccine mandates for groups like health workers – even though the virus still remained the fourth leading cause of death in the US in 2022.

Transform the suffering into meaningful and lasting change

But even as so-called ‘normalcy’ returns, Tedros urged global health leaders to rapidly conclude negotiations on a strong Pandemic Accord, as well agreeing to amendments in the existing WHO International Health Regulations (IHR), to avoid repeating the mistakes of the COVID pandemic once more.

“One of the greatest tragedies of COVID-19 is that it didn’t have to be this way,” Tedros said. “We have the tools and technologies to prepare for pandemics better, to detect them and then to respond to them faster and to mitigate their impact.  But globally, a lack of coordination, a lack of equity, and the lack of solidarity meant that those tools were not used as effectively as they could have been.  Lives were lost that should have been.

“We must promise ourselves, and our children and grandchildren that we will never make those mistakes again,” he said describing the draft treaty and IHR revisions as representing a “commitment to future generations that we will not go back to the old cycle of panic and neglect that left our world vulnerable.

“… If we all go back to the way things were before COVID-19, we will have failed to learn our lessons.”

Huge strides made should not be lost

Mike Ryan, WHO Executive Director, Health Emergencies

WHO’s Health Emergencies Executive Director Mike Ryan, echoed those sentiments noting how the COVID pandemic saw huge strides made in the expansion of national disease surveillance systems, laboratory testing, clinical care, and access to life-saving tools from new vaccines to oxygen.

“The challenge is really how to we keep up this momentum,” he observed, “because it’s not only important for COVID, it’s important for other diseases that are in circulation.

“We need the world to get into a preparedness mode,” he added.  “We can’t just keep responding and responding and responding.  We have to get the inequities out of our system.  We saw people in this pandemic literally bargaining for oxygen cannisters on the streets of major cities. This is the 21st century.  Is this what we want to witness in the next pandemic?

A COVID patient breathes in life-saving oxygen outside an overcrowded New Delhi hospital at the height of India’s COVID surge in 2021.

“We saw family members physically fighting to get their loved ones into a hospital bed.  We saw people die before they got to the emergency room. That’s the reality of our preparedness.  We talk about technology but we can’t just use technology to get out of the mess we’re in.  We have to address our systems. We have to address how we govern.  We have to address how we finance.”

Negotiating teams have just a year to reach broad consensus

Wholesale markets in Asia and Africa may often sell wild animals captured or bred for food consumption; SARS-CoV2 may have emerged from such a Wuhan market.

Within WHO, there are two member state groups leading negotiations on a draft pandemic accord and revisions in existing WHO health emergency (IHR) rules. The two bodies, the Intergovernmental Negotiating Body (INB) and the IHR Working Group have just one more year to complete their work in line with a mandate to bring draft agreements to the World Health Assembly by May 2024.  They are planning a joint meeting soon in an effort to sort out what topics, among the multiple issues facing negotiators, would better be handled in one instrument as compared to the other.

Together, they face a formidable task in reaching WHO member state consensus over a raft of issues – from measures to ensure stricter monitoring and reporting by countries of emerging threats to more sustainable financing of developing country health systems and more equitable distributions of vaccines, medicines and other vital health tools.

Along with that, climate change, ecosystem destruction, and poorly regulated wildlife markets and trade are constantly increasing the risks of zoonotic spillover of new and resurgent diseases from animals to humans. And these are problems that the health sector cannot effectively address without the active consent and collaboration of economic and environment sectors.

Appeals to UN General Assembly to show leadership

Ellen Johnson Sirleaf, former Liberian president and former co-chair of the Independent Panel.

The problems go beyond what WHO alone can handle, some leading advocates have asserted, calling for the UN General Assembly to play a more active role going forward. The UN General Assembly is scheduled to hold a high level meeting on pandemic preparedness, prevention and response on 20 September – with a civil society stakeholder meeting set for next week.

Among the voices calling for more UN-wide leadership are Helen Clark and Ellen Johnson Sirleaf, former co-chairs of the Independent Panel on Pandemic Preparedness and Response, which issued a scathing report to WHO in May 2021. On Thursday the two former co-chairs issued a new “Road Map”  calling for more assertive action by the UNGA alongside WHO.

“Bold political choices to protect the world” are needed, the report states, including UN-wide agreement on stronger international pandemic rules, equitable countermeasures and an independent monitoring body working alongside an “authoritative WHO”.

In terms of finance, at least US$10.5 billion annually is needed to support low- and middle-income countries to bring health systems preparedness up to par.  So far, only about 10% of that has been committed to a new World Bank-hosted Pandemic Fund. Debt relief for overstretched developing nations and innovative forms of climate and sustainable development finance also are critical to pandemic prevention, the report states, referring to the “Bridgetown Agenda” championed by Mia Mottley, prime minister of Barbados.

“At a time of difficult geopolitical divide, the UN General Assembly High-Level Meeting presents an historic opportunity to demonstrate the power of multilateralism and political leadership, and choose human collaboration to overcome the threat of pathogens that could materialise anywhere, anytime,” said Helen Clark, former Prime Minister of New Zealand.

“We will face new pandemic threats. The UNGA must draw on the hard lessons from COVID-19 and honour the memory of the many millions of people who have died, to commit to comprehensive reforms that leave no gaps in the system this time,” said Johnson Sirleaf, former president of Liberia.

Image Credits: Thomas Hackl/Flickr, Flickr, Peter Griffin/Public Domain Pictures.

INB co-chair Precious Matsoso

Equity and intellectual property (IP) rights are – unsurprisingly – the most important and trickiest issues facing countries negotiating the terms on which the next global pandemic will be addressed.

This emerged at a World Health Organization (WHO) briefing on Thursday addressed by Precious Matsoso, co-chair of the Intergovernmental Negotiating Body (INB) crafting a pandemic accord, and Dr Ashley Bloomfield, co-chair of the working group on amendments to the International Health Regulations (IHR).

Matsoso said that IP was being raised in discussions about how to “stimulate innovation” and “facilitate access” to pandemic-related products, including vaccines and medicines.

Meanwhile, Bloomfield said that a key discussion in the IHR working group was how to “effectively put equity into operation through the regulations”, particularly aiming at improving member states’ capacity to address future pandemics. 

“[The discussions] are around the funding for that, and they are around access and benefit sharing and, in particular, access to the technologies that are derived from the sharing of viral samples – in particular vaccines, but also treatments,” said Bloomfield, adding that these were also issues being discussed by the INB.

Combined processes

There is only a year left for both to complete negotiations on both a pandemic accord and changes to the IHR, the only globally binding rules to guide international disease outbreaks. Both the draft accord and proposed amendments are due to be presented to the 2024 World Health Assembly.

As there is significant overlap in the work of the INB and the IHR working group, they are currently planning a joint meeting, said Matsoso.

“Member states in a number of meetings have raised this issue of the overlaps and duplications, and they’ve called on us to bring these processes closer and ensure that we can delineate those areas that belong to different parts,” said Matsoso.

“We see this as a continuum because, you can imagine, if you’re in a country, and you’re hit with a pandemic and you have to refer to both these instruments once they’re adopted, there must be a systematic way in which they are followed,” said Matsoso.

“Our task is both bureaus (technical leads for the two processes)  is to help member states to organise this in such a way that there’s coherence and the synergy, but also a continuum so that they don’t see [the two instruments] as separate processes.”

Dr Ashley Bloomfield, co-chair of the IHR working group.

Bloomfield added that the bureaus “have met several times already together, virtually, and our last meeting most recent meeting was just a couple of days ago”.

At that meeting, bureau members had started to “shape up this request that we’ve got from both processes from the member states to hold a joint session to start to address these issues that we have in common”. 

For some member states, the same representatives are negotiating in both the INB and the IHR working group. Meetings have thus usually been organised “adjacent and back to back” to help these representatives, primarily from African countries and small island states.

Pandemic oversight

One of the weaknesses of the IHR is that there is insufficient monitoring, oversight and compliance with the regulations.

The US, Africa region and the European Union have all made proposals to address this gap, said Bloomfield.

“There’s quite a lot of similarity between those proposals so there’s work underway to see if we can get a single convergent proposal,” he said. 

“The tenor of the discussion we have had is very much of the flavour that we should be looking to how we can incentivize and support countries to implement the IHR in full and to comply with their obligations, rather than sanction,” he added.

Matsoso said that, within the INB, proposals had been made about peer review mechanisms, adding that “punitive measures have not been shown to work anywhere… But there must be some accountability mechanisms”.

National sovereignty

Panellists expressed surprise at the ongoing mis-and disinformation about how the pandemic negotiations would result in member states losing their national sovereignty to the WHO.

WHO Principal Legal Officer Steven Solomon described the two processes as “some of the most transparent in the history of WHO’s work on global health instruments”. 

WHO Principal Legal Officer Steven Solomon

“Member state-driven means that member states decide and, in the context of preparing instruments like this it means specifically that member states, countries, make the proposals,” said Solomon.

“Countries do the drafting country, do the negotiating, the work and finding consensus. Countries make the decision on what is to be agreed and then, under the Constitution, countries adopt whatever the outcome might be in the World Health Assembly,” he added. 

“Even at that point, this does not mean acceptance by a country after adoption in the Health Assembly, which is a formal act. Then countries individually must consider and decide whether they accept what was adopted in the Health Assembly. So there’s nothing automatic that happens in terms of the entry into force of whatever will be adopted at the Health Assembly.  Countries themselves will decide to accept or not the outcomes of that process of the assembly.”

Bloomfield also stressed that, despite the “myths and disinformation”, “member states are in the driving seat and they are the decision-makers”.

“It’s not really an issue that is troubling the discussions we’re having in the working group because all those people are fully aware of the mandate they have from their governments.”

RSV
On Wednesday, GSK’s Arexvy vaccine became the first in the world to be approved for use against the respiratory syncytial virus (RSV).

The US Food and Drug Administration (FDA) has approved the first-ever vaccine for respiratory syncytial virus (RSV). The single-shot vaccine intended for use in adults aged 60 or older represents the culmination of six decades of research to protect the world from RSV.

With the green light from the FDA on Wednesday, GSK’s Arexvy vaccine could be available as early as this fall, officials said. The speed of the vaccine’s public rollout hinges on receiving the final stamp of approval from the US Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices, which will meet in June.

RSV is a virus that kills over 100,000 children under the age of five every year. While RSV’s cold-like symptoms are often viewed as non-threatening to adults, the virus kills around 14,000 adults in the United States every year and has an annual global death toll of 160,000 people.

“Today’s approval of the first RSV vaccine is an important public health achievement to a disease which can be life-threatening,” said Dr Peter Marks, who heads the Center for Biologics Evaluation and Research at the FDA.

The US FDA approval follows its review of the data from an ongoing randomized control trial of nearly 25,000 older adults. Results from the study published in the New England Journal of Medicine in February showed the GSK vaccine reduced the risk of developing lower respiratory tract disease, which is caused by the virus, by 83%. It also reduced the risk of contracting severe lower respiratory tract disorder by 94%.

Dr Len Friedland, director of scientific affairs and public health at GSK, acknowledged the occurrence of several serious adverse side-effects throughout the study, but said they were evenly split between the group that got the vaccine and the one that received the placebo. Researchers would continue to monitor the vaccine’s safety profile as the trial moves forward, he added.

The most common minor side effects observed in the participants were injection site pain, fatigue, muscle pain, headache and joint stiffness.

A battle since the 1960s

Scientists have been trying to figure out a way to combat RSV since the 1960s. Between 1966 and 1968, a promising clinical trial for an early RSV vaccine candidate went badly wrong, killing two young children involved in the trials. Many more children vaccinated as part of the study needed to be hospitalized, with some suffering from more severe forms of RSV as the vaccine backfired.

It wasn’t until years later that scientists discovered that the protein inside the RSV virus shifts between two shapes, similar to the coronavirus SARS-nCOV-2. The shape-shifting nature of the protein meant scientists were trying to hit a moving target. The protein eluded the aim of scientists until 2013 when researchers from the National Institutes of Health (NIH) found a way to freeze the protein in one of its two shapes, allowing the development of vaccines targeted at the now immobile protein.

While RSV has long been a regular virus in the winter seasons, it gained attention when thousands of young children and older adults began filling up hospitals during the summer seasons in 2021 and 2022.

In 2020, most of the world was still under the COVID-19-induced lockdown and following precautionary measures like using face masks and frequently washing hands. As those precautionary measures were lifted, vulnerable groups of people began contracting RSV and ending up in hospitals.

Other RSV vaccines in the queue

The US FDA is set to decide on another RSV vaccine by the end of May. This vaccine is also targeted at older adults and is manufactured by Pfizer. If approved by the FDA, Pfizer’s vaccine will be up for final approval for public use alongside the GSK vaccine when the CDC’s Advisory Committee on Immunization Practices meets in June.

Another vaccine by Pfizer is also awaiting approval from the FDA by the end of August. This vaccine targets infants susceptible to RSV and, if approved, will be administered to pregnant women.

Moderna and Bavarian Nordic are also currently in phase-3 of clinical trials for their RSV vaccine candidates for older adults.

Image Credits: NIAID.

There is widespread speculation that the World Health Organization (WHO) will decide that COVID-19 is no longer a “Public Health Emergency of International Concern (PHEIC)” when its expert group convenes on Thursday.

The 15th meeting of the Emergency Committee for COVID-19 has been convened by the WHO Director-General in terms of the International Health Regulations (IHR).

Fueling the speculation is the WHO’s release late on Wednesday of a 20-page “updated COVID-19 Global Strategic Preparedness, Readiness and Response Plan (SPRP) 2023-2025”.

The document is a guide for countries on how to manage COVID-19 over the next two years “in the transition from an emergency phase to a longer-term, sustained response”, according to the global body.

WHO Director General, Dr Tedros Adhanom Ghebreyesus notes in the foreword that, aside from the usual objectives of reducing the circulation of SARS-CoV-2 and diagnosing and treating COVID-19, the plan adds a third objective: “to support countries as they transition from an emergency response to longer-term sustained COVID-19 disease prevention, control and management”. 

“We do not propose that countries abandon the 10 pillars that served as a foundation for the pandemic response,” adds Tedros. “Rather, the new strategy aligns these 10 pillars with the five core components of equitable, inclusive and effective health emergency preparedness, response and resilience: collaborative surveillance, community protection, safe and scalable care, access to countermeasures, and emergency coordination.”

The focus is on restoring, reinforcing and strengthening health systems, as well as “integrating COVID-19 surveillance and management into that of other respiratory diseases”. 

Long COVID focus

The new plan places a strong emphasis on long COVID, which may affect as many as 6% of those infected with COVID-19. It calls for more research to better understand the post-COVID condition, “including its risk factors and the role of immunity, and to develop methods to better quantify its burden”.

“Although we are in a much stronger position in facing the COVID-19 pandemic, the virus is here to stay and countries need to manage it alongside other infectious diseases,” according to the WHO.

Meanwhile, the WHO’s coronavirus dashboard notes no new COVID-19 cases have been reported in the past 24 hours – although it is widely recognised that many countries are no longer monitoring new infections.

In late March, the WHO Strategic Advisory Group of Experts on Immunization (SAGE) decided that additional COVID-19 vaccine boosters were not recommended for people at low to medium risk of the disease who have been vaccinated and boosted once.

SAGE recommended an additional booster six to 12 months after the last dose for “high priority” people, depending on factors such as age and immuno-compromising conditions.

On Monday, the US announced that it would end COVID-19 vaccine mandates for international travellers, health workers in hospitals and federal employees on 11 May.

“While vaccination remains one of the most important tools in advancing the health and safety of employees and promoting the efficiency of workplaces, we are now in a different phase of our response when these measures are no longer necessary,” said the White House.

Image Credits: Vital Strategies.

Dr Anthony Fauci, former Director of the National Institute of Allergy and Infectious Diseases, was attacked and vilified during the COVID-19 pandemic.

The conspiracy-based anti-science attacks on scientists and vaccines that proliferated during the COVID-19 pandemic in the US are likely to have chilling, long-term effects on biomedicine, according to Professor Peter Hotez, Dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston. 

The biggest casualty may be childhood vaccinations, leading to a surge in diseases that had been almost eradicated such as measles, whooping cough and polio, writes Hotez in FASEB BioAdvances journal.

Polio cases in New York city and an outbreak of measles in unvaccinated children in Ohio already bear this out.

Confidence in childhood vaccines has already dropped considerably during the pandemic, with 35% of US parents now opposed to routine immunisations being required before children could enroll in school, according to a Kaiser Family Foundation report in December 2022.

Meanwhile, a 2021 survey by YouGov found that less than half (46%) of parents who supported the Republican Party were in favour of childhood vaccines being mandatory for school attendance in contrast to 85% of Democrats. Overall, support for vaccine mandates dropped by 4% between 2020 and 2021.

The effect of Republican politicians’ promotion of anti-vaccine conspiracies has already been seen in COVID-19 death statistics, with Republican (“red”) states recording much higher death rates.

“During Delta, COVID-19 vaccinations exhibited over 90% protective immunity versus death and yet an estimated 40,000 Texans died because they declined to get immunized,” writes Hotez, who is based in Texas.

“Nationally, that number of unnecessary deaths was approximately four to five-fold higher. The analyses from The New York Times and healthcare data specialist, Charles Gaba, reports that those deaths overwhelmingly occurred in conservative or Republican-majority states. Moreover, the ‘redder’ the state in terms of voters, the lower the immunization rates, and the higher deaths climbed.”

Hotez cites multiple examples of Republican politicians discrediting the effectiveness and safety of COVID-19 vaccinations during the Delta and Omicron waves. The US has one of the highest global COVID death rates per capita in the world, with 1.1 million deaths.

“Thousands of Americans in conservative states believed it all, and they paid with their lives. They fell victim to a coordinated campaign of antiscience aggression. Its three major elements included anti-vaccine and antiscience rhetoric from federal and state elected officials, together with amplification nightly on Fox News (and other news outlets) and academic cover from a few universities and extremist think tanks,” argues Hotez.

Demoralising effect

Professor Peter Hotez has been harassed by anti-vaccine protestors.

Hotez, who has been subjected to persistent harassment by anti-vaccine protestors, warned that the anti-science movement will “demoralize biomedical scientists”, many of whom already report that they “live in a climate of fear” as they face an “avalanche of abuse” via emails, social media and physical confrontations.

The “unprecedented distrust of scientists” could result in a reduction in federal support for the National Institutes of Health (NIH) and other biomedical research institutions, and discourage university students from pursuing careers in the sciences. 

“I am regularly targeted online through social media and emails, as well as phone calls and even in-person confrontations. The Florida Governor has disparaged me on Fox News, despite my correct predictions regarding COVID-19 in his state, while about Dr Anthony Fauci he stated his desire to have ‘that little elf’ thrown “across the Potomac [River]”.

Fauci, the former director of the National Institute of Allergy and Infectious Diseases and chief medical advisor to the president from 2021 to 2022, has faced almost constant derision and death threats during the pandemic.

Urgency to respond

Given that the rise in anti-science sentiment could undermine the future of biomedical science in America, Hotez argues that it is essential for both US President Joe Biden and the Office of Science and Technology Policy (OSTP) to respond. 

“The political drivers for the assaults on biomedical science and scientists remain unclear, but they resemble those directed against climate science and scientists that began a decade ago,” he notes.

“During the 20th century, science and scientists were attacked as part of larger ambitions for authoritarian control in the USSR and elsewhere. The motivation may be similar.”

Possible responses include “a federal plan to preserve science and protect American scientists” and a legal defence fund for scientists

As the pathogen causing the next pandemic may have both high mortality rates and transmissibility “we must find ways to limit the flow of disinformation to ensure that life-saving vaccines and therapeutics do not go unused as they did in America during the time of COVID-19,” he urges.

“More complicated is how we limit the spread of disinformation in a free and open society committed to first amendment rights. This concern must be balanced with the stark reality that anti-science aggression is causing a substantial loss of human life, possibly in the hundreds of thousands according to some estimates,’” he adds.

“All indications so far suggest that the biomedical scientific community has not prepared adequately, and there are few plans to counter these politically motivated attacks.”

Image Credits: flickr/The White House. Official White House Photo by Andrea Hanks.

A doctor at Ifakara District Hospital in Tanzania treating a malaria patient

The momentum from last week’s World Malaria Day needs to translate into more resources to address the global funding shortfall to achieve 2030 malaria targets.

Since the turn of the century, global partnership and sustained investment have completely transformed the fight against malaria – preventing two billion malaria cases, saving 11.7 million lives, and putting eradication within reach. 

Figures like these were very much in the spotlight last week as World Malaria Day took centre stage to highlight the progress that’s been made in the fight against malaria so far, as well as the further steps that still need to be taken. But it’s vital that the conversation about malaria eradication is sustained beyond this important day, and action is increased to deliver against this goal. 

As we now look towards the World Health Assembly at the end of the month, we hope to see an increased commitment to ending this deadly disease.

As more countries approach malaria elimination, progress has started to slow in the countries with the highest rates of the disease – mostly in sub-Saharan Africa. Low coverage of existing tools, emerging biological threats, and a shortfall in global malaria funding prevents these countries from reaching global malaria targets. 

In 2021, malaria cases increased to 247 million, contributing to over 600,000 preventable deaths, according to the World Malaria Report 2022.

Converging biological threats

Between 2021-23, global funding for malaria control has fallen by $4.8 billion – less than half the total funding required to deliver national programmes.

This is a tragic situation and a situation that remains precarious. At the same time, half the world’s population lives at risk of the disease.

With several biological threats converging and threatening to increase the spread of malaria, the stakes are higher than ever. The growing threat of insecticide and antimalarial resistance will have significant implications on the effectiveness of the tools at the heart of efforts to end malaria, such as nets, treatments, insecticide spraying, and diagnostic tests.

While many countries pledged $15.7 billion to the Global Fund’s Seventh Replenishment last year (which serves as a significant source of funding for tackling malaria), in addition to the Presidential Malaria Initiative and the Bill and Melinda Gates Foundation, this was far less than needed to accelerate the fight against these diseases and achieve global targets. Countries are now faced with the enormously difficult task of increasing malaria control measures with even less funding than before.

Now is not the time for the world to step back from our commitments to end malaria – quite the inverse.

New tools but shortage of resources

An infant receiving the RTS,S malaria vaccine in Ghana in 2019. New malaria vaccines hold the promise of significantly reducing childhood infections and severe malaria cases.

The good news? We have new tools to respond to these threats. Existing investments in R&D have produced the most robust pipeline of malaria interventions in over a decade to address emerging threats and transform the fight against malaria. But many of these proven interventions are waiting to be implemented at scale. Countries will not reap the rewards of these investments without financing the scale-up and rolling out of these innovations where they’re needed most.

We now have a window of opportunity to galvanise action and accelerate progress to achieve 2030 targets, but countries must act fast. They continue to work tirelessly to hold the line against malaria by implementing innovative approaches to tailor and deliver lifesaving tools to the most vulnerable and hard-to-reach. Still, without sufficient investment and efficient use of available resources, they risk losing further ground.

Global leaders, countries, the private sector, and all partners must urgently deliver bold malaria control and elimination investments. Only by innovating and bringing new tools, implementing new approaches targeting and tailoring the most in need, and bridging these funding gaps can we accelerate progress against this age-old disease and ultimately achieve a zero-malaria world.

Dr Corine Karema is Interim CEO of the RBM Partnership to End Malaria. 

Image Credits: Peter Mgongo, WHO.